GI Flashcards
1
Q
Repair of small choledochotomy
A
Repair with 4-0 or 5-0 PDS
Leave drain
2
Q
Repair of long choledochotomy
A
Use a T tube - as big as duct will accommodate
Shoot cholangiogram
3
Q
30% injury to CBD - repair?
A
Try to primarily repair
Place t tube remote to injury
Shoot cholangiogram
4
Q
Repair of esophageal leak s/p dilation for achalasia - 2 cm defect
A
Left lateral decubitus Posterolateral thoracotomy Take down inf pulm ligament Mobilize distal esophagus Repair in 2 layers - Contralateral myotomy to repair ext 5 cm below GEJ*** Intercostal muscle flap over repair Chest tubes Consider feeding access Leak test
5
Q
Lap nissen
A
Open up hiatus by incising phrenoesophageal ligament and mobilize distal esophagus to get adequate intra abdom length (2-3 cm)
During dissection ID and protect vagus nn
Close hiatus
Complete mobilization of fundus and pass posteriorly
Carry out fundoplication over 60Fr bougie approx 2-3 cm in length
EGD to ensure not too tight
6
Q
Repair of esophageal leak s/p dilation for achalasia - 2 cm defect (distal)
A
Right lateral decubitus
Left posterolateral thoracotomy - 7th intercostal space, harvesting intercostal muscle flap for future buttress
Mobilize distal esophagus, debride necrotic tissue, vertical myotomy to fully expose mucosa
2 layer repair: vicryl inner, silk outer
Intercostal muscle flap to buttress repair
Perform contralateral myotomy** if underlying achalasia
Leak test through an NG tube passed by anesthesia just proximal to injury and passed into stomach
Irrigate
2 chest tubes
Establish enteral access - J tube
7
Q
Repair of esophageal leak s/p dilation for achalasia - 4 cm defect
A
Exclusion and proximal diversion
Can divert proximally via spit fistula - loop
Get thoracic mucocele
G tube for feeds
8
Q
Normal DeMeester
A
14.72
9
Q
3 point suture ligation for bleeding duo ulcer
A
Longitudinal duodenotomy* Superiorly Medially Inferiorly **take care to avoid CBD** Close duo transversely
10
Q
Presacral bleeding during APR
A
Pack off pelvis
Communicate w/anesthesia
Can use abdominal tacks, bone wax etc
11
Q
4 cm defect of ureter at pelvic brim
A
Mobilize bladder and ureter
Primary ureteral repair - spatulate 2 ends, repair over double j stent using 4-0 PDS, drain
Can swing it out to the skin as cutaneous ureterostomy or can tie off and plan for perc nephrostomy post op
12
Q
Workup when suspicious for esoph perf
A
CXR, EKG
Abx (broad spec - vanco, diflucan, zosyn)
13
Q
Adherent clot on EGD
A
Inject epi into 4 quadrants around clot base
14
Q
Forrest Ia
A
Spurting hemorrhage
15
Q
Forrest Ib
A
Oozing hemorrhage
16
Q
Forrest 2a
A
Visible vessel
17
Q
Forrest 2b
A
Adherent clot
18
Q
Forrest 2c
A
Hematin on ulcer base
19
Q
Forrest 3
A
No active bleeding/recent bleeding sx
20
Q
Endoscopic tx not recommended for which forrest classes?
A
2c or 3
21
Q
Stable patient, bleeding gastric ulcer - OR
A
Ex lap, upper midline laparotomy
Anterior gastrotomy
Oversew ulcer
If refractory disease – can consider truncal vagotomy + antrectomy/pyloroplasty
22
Q
If oversewing duodenal ulcer, how can you help ID the CBD?
A
Can insert pediatric feeding tube through the papilla
23
Q
How to ID GDA if bleeding continues from ulcer despite 3 point ligation
A
Can be identified superior to duodenum and ligated at origin
24
Q
Pancreatic cyst - what else are you looking for on CT scan?
A
Size, where, any nodularity or solid component, is duct dilated, other cysts, calcifications, nearby surrounding structures - is it invading blood vessels, lymphadenopathy, ascites
25
Pancreatic cyst characteristics to analyze for
Mucin, CEA, amylase, cytology
26
Pancreatic fistula/leak - options?
IR drainage
Ask GI to place pancreatic stent
Re-operate
27
Gastrinoma triangle
2nd and 3rd portion of duo
Neck and body of pancreas
Junction of common and cystic duct
28
Gastrinoma within duodenal bulb
Small duodenotomy
| Enucleate
29
Unable to localize gastrinoma through imaging
Intraoperative US
| Can try to do EGD - transilluminate (lesions are submucosal)
30
Acute recurrent paraesophageal hernia
Relaxing incision on each side of crura
| Mesh
31
ID location of GI bleed - options to localize
```
C scope
CTA
Tagged RBC
Smart capsule
Provocative angiogram
```
32
Small bowel bleed - options?
Can try double ballooned enteroscopy
33
Last ditch effort to localize small bowel GIB
Mini laparotomy
Bring up diverting loop ileostomy
Perform endoscopy
34
Slipped gastric band
Enter epigastrum through optiview
2 addn ports on either side
Find band, grab silicone tubing and incise directly onto the capsule
Cut clasp, pull it out
35
Gastric band erosion
EGD following removal of band to assess for leak
| UGI in 2 days post op
36
NGT lavage with clear fluid return - should ask?
If bile was present as well. If not, perform EGD
37
Heller Myotomy - OR
Liquid diet 48 hrs prior
NGT prior to induction
Triangulate ports to hiatus
Perform hiatal dissection to expose GEJ and anterior esophagus
ID and protect vagus nerve
Divide longit and circumferential muscles to ensure to separate muscle fibers from underlying mucosa
for a length of 6 cm onto esophagus and 2 cm onto stomach
EGD and insufflation leak test
Anterior 180 degree fundoplication
38
Post op course s/p Heller Myotomy
Esophagram POD1 - if negative for leak, clear liquids
Day 3 - mechanical soft
Adv to regular after 3 weeks if doing well
39
Internal hernia s/p RYGB - OR
NGT, measuring carefully to avoid damage to depth
Supine with arms tucked
Hassan @ umbilicus
3-4 additional 5 mm ports to allow to run bowel
Start at TI and run common channel until reach point of obstruction at JJ
40
Internal hernia locations s/p RYGB
MC - mesenteric defect at JJ
Petersens defect - behind roux limb mesentery
Through rent in transverse mesocolon if this was constructed retrocolic
41
Small bowel intussusception at JJ s/p RYGB
Reduce with gentle traction
If cannot reduce, small supraumbilical incision. Gentle traction distally while gently squeezing and applying pressure proximally
42
Reconstruction after RYGB
Measure individual limbs prior to resecting anastomoses
Tailor recon based on pts weight and nutrition status
Reestablish continuity with stapled SSA between roux limb and common channel
Plug BP limb at least 30 cm up or downstream depending on absorptive capacity
43
ECF takedown
```
Ex lap with meticulous LOA
Removal of any foreign material
Resection of any fistula tract and any pathologic bowel with restoration of continuity
May require temp or perm stoma
+/- abdom wall reconstruction
```
44
What size t tube to use when repairing CBD injury
Whatever size the duct will accommodate
45
Any time you use a t tube to repair CBD injury whats your next step
Shoot cholangiogram through the tube
46
CBD injury 30% ish or non thermal
place t tube remote (usually distal to injury)
47
How quick should gastric ulcer heal
within 8 weeks if on PPI
48
Repeat endoscopy - unchanged gastric ulcer
R/o malignancy
Check fasting serum gastrin
EUS, FNA
Staging CT
49
Refractory gastric ulcer, bx benign - OR
Wedge resection
| Send for FROZEN**
50
Path gastric ulcer- T2 N1, positive proximal gastric margin - OR?
Total gastrectomy
51
Post splenectomy presents with fever - must ask?/
Did they get their vaccines!!!
52
When can you expect pancreatic fistula to resolve prior to resorting to ERCP
3-6 weeks
53
Refractory duodenal bulb ulcer despite PPI, stable pt
Truncal vagotomy + pyloroplasty - extend perforation across pylorus and close transversely
Could also do highly selective vagotomy + patch
54
Pyloric exclusion - OR
```
Staple across pylorus using TA
Widely drain
B2 recon
Triple tube therapy:
G tube in stomach
J tube in efferent limb for feeding
Retrograde duodenal tube in afferent limb -- tip in the crater of ulcer
```
55
Ways to assess bowel viability
Moist lap sponge, see if pinks up after few min
Doppler mesentery
Admin fluorescein dye IV and use woods lamp
Admin ICG and perform near infrared fluorescence
56
Early post op SBO
2 weeks post op - most hostile
Stay conservative as possible
Provide nutrition support, decompression
Wait for about 4 weeks prior to re-OR unless emergency
57
ECF - important hx to obtain
Prior surgeries and details
IBD
DM II
Hx skin infections esp MRSA
58
ECF - 4 main principles
Control sepsis (r/o intra abdom source of infection)
Define anatomy (CT, fistulagram)
Control effluent/protect skin
Optimize nutrition
59
Barretts histopathological changes
Squamous --> columnar
60
Barretts w/o dysplasia surveillance
Surveillance EGD q3-5 years
61
Barretts w/low grade dysplasia
Surveillance every 6-12 mos +/- eradication
62
Barretts w/high grade dysplasia
eradication vs surveillance q3 mos
63
Leak s/p cervical esophagectomy mgmt
If drain is in place, should be adequate
Use J tube for feeds or start TPN
Abx, etc
64
Tx of GOO
Can try BID PPI - 20% will open up w/o surgery
Otherwise BII GJ
Eventually subtotal gastrectomy with roux en y if not opened up in 6 weeks
65
GOO - first best test
UGI
| Then EGD, CT scan etc
66
Neoadjuvant therapy for esophageal CA
CROSS regimen
| Carboplatin, paclitaxel + XRT
67
Esophagectomy - OR
Start with abdominal portion
Mobilize gr curvature, preserving gastroepiploic arcade
Kocher maneuver to help conduit reach into chest
Mobilize stomach and ligate L gastric a at base, keeping lymphatic tissue with specimen
Mobilize remainder of stomach and perform hiatal dissection, keeping lymphatic tissue
Create gastric conduit by transecting stomach at least 5 cm distal to tumor, creating long conduit based on gr curvature
Suture to specimen so it can be pulled into chest
Reposition for R thoractomy - ask for thoracic surgery help
R lateral thoracotomy and mobilization of esophagus and surrounding soft tissue including lymphatics up to azygus v
Staple off esophagus, bring conduit into chest and circular stapler used for anastomosis
2 chest tubes for drainage
68
Staple line breakdown s/p gastric sleeve
Use EGD
| Oversew area of leak with scope in place
69
Normal appendix, terminal ileitis
Appendectomy if the terminal ileitis doesnt involve base
70
Appendicitis + terminal ileitis
Leave both alone
71
Where do you put g tube in bypass pt
Remnant stomach
In sleeve --> j tube
72
Choledocholithiasis.- initial maneuvers
0.2 mg glucagon
5 min later, attempt to flush
Stone basket through cystic duct
73
Choledocholithiasis s/p RYGB
Consider transduodenal sphincterotomy
| If that doesnt work --> hepaticojejunostomy
74
Marginal ulcer tx
PPIs, sucralfate
75
GIST arise from...
interstitial cells of Cajal
76
Incidence of GIST in various locations
Stomach (46%)
SI (25-30%)
Rectum (5-15%)
77
Exon 15 significance in GIST
Relatively resistant to imatinib
78
Factors impacting likelihood of adjuvant imatinib
Tumor size, location and mitotic rate
79
Adjuvant imatinib indications - general
>5 cm and >5 mitoses/50 HPF
| >10 cm or >10 mitoses/50 HPF
80
rec length of roux limb
at least 100 cm but up to 150 cm in "super obese"
81
Subtotal gastrectomy - OR
Staging lap
Upper midline incision
Separate omentum from transverse colon and proceed toward proximal greater curvature using Ligasure stopping short of short gastrics**
Divide R gastroepiploic a and v
Mobilize lesser curvature (being mindful of replaced or accessory left hepatic a)
R gastric artery is divided
Divide duodenum distal to pyloric ring using TA stapler and oversew staple line with 3-0 silk lemberts
Left gastric a divided at origin
Stomach divided at least 5 cm proximal to cancer using green load of GI stapler
Stapled end to side roux en y gastrojejunostomy
Fashion a roux en y jejunal limb 40-60 cm long to avoid biliary reflux
Bring limb retrocolic
Close defect
82
Truncal vagotomy - OR
Midline lap
Incise phrenoesophageal ligament
Circumferentially dissect esophagus and pass Penrose drain
Retract gus to right and posterior for left (anterior) nerve
Retract gus to left and anteriorly for right (posterior) nerve
Isolate at least 2 cm of trunk above GEJ and divide between clips
Send to path for confirmation
*drainage procedure*
83
Why is drainage needed following truncal or selective vagotomies
Patients lose antral pump function and vagally mediated receptive relaxation --> delayed emptying of solids, accelerated emptying of liquids
84
Truncal vs selective vagotomy
Selective involves division of trunks DISTAL to the origins of the hepatic and celiac branches
85
First branch of posterior vagal trunk and what does it innervate
Criminal nerve of grassi
Innervates gastric fundus
Failure to divide results in recurrent ulcers
86
Selective vagotomy - OR
Fibrofatty trissue overlying GEJ is thinned and anterior trunk identified
Tent up anterior trunk which tents hepatic vagal branch - follow proximally to junction with anterior vagal trunk
Continuation of vagal trunk DISTAL to this junction traveling along lesser curve divided
Identify posterior vagal trunk, encircle with vessel loop and retract
Should tent up celiac vagal branch to celiac axis --> follow barnch to junction with posterior vagal trunk
Continuation of vagal trunk distal to this junction traveling along lesser curve divided
87
Highly selective vagotomy - OR
Divide gastric vagal branches only so far as the antrum
To find the distal limit, measure 6-7 cm cephalad to pylorus and find crows foot of vagus along anterior surface of stomach
Need to divide neurovascular bvundles in both anterior AND posterior leaflets of gastrohepatic omentum
Divide close to stomach
Once reach GEJ, clear all tissue to ensure any residual nerve fibers are ligated included incl Criminal Nerve of Grassi
88
Heineke-Mikulicz pyloroplasty - OR
Kocher maneuver
Grasp peritoneum lateral to duodenum and incise sharply
Mobilzie duo and head of pancreas to just before lateral aspect of SMV
ID pylorus by palpation
2 cm proximal to pylorus on antrum, incise gastric wall, enter lumen, extend distally parallel to long axis of bowel across pylorus onto duodenum for distance of 5 cm
Close longitudinal pyloroplasty with single layer sutures in transverse fashion
89
Billroth I - OR
Midline lap
Divide falciform ligament to place self-retaining
Gastric mobilization (incise gastrocolic ligament to enter lesser sac, prox dissection to midpoint of greater curvature and distally to beyond pylorus, divide R gastroepiploic a and ligate)
Divide gastrohepatic ligament along lesser curve carried proximally to incisura and distally to R gastric A (ligate)
Divide stomach and duodenum using stapler
2 layer anastomosis - PDS for inner layer and silk for anterior layer
90
Cons of Billroth I
Lack of pylorus increases risk of bile reflux gastritis
91
Cons of Billroth II
Enterogastric reflux
Early dumping
Higher risk for carcinogenesis
92
Billroth II - OR
Midline lap
Divide falciform ligament to place self-retaining
Gastric mobilization (incise gastrocolic ligament to enter lesser sac, prox dissection to midpoint of greater curvature and distally to beyond pylorus, divide R gastroepiploic a and ligate)
Divide gastrohepatic ligament along lesser curve carried proximally to incisura and distally to R gastric A (ligate)
Divide stomach with stapler
Oversew staple line with 3-0 silk
Divide duodenum distal to any disease wit hstapler and buttress closure with 3-0 silk, secure omentum over suture line
Isoperistaltic, retrocolic gastrojejunostomy as close to LoT as possible (10-15 cm) to reduce risk of afferent limb
45 mm stapled GJ formed by creating posterior wall gastrotomy and antimesenteric enterotomy
Common enterotomy closed with 3-0 PDS full thickness and overlying 3-0 silk
Close mesenteric defect
93
If duodenal ulcer involves ampulla - next step?
Can stick biliary fogarty into CBD to mark locationm
94
Layers of gastric wall on EUS
```
Superficial mucosa
Deep mucosa
Submucosa
Muscularis propria
Serosa
```
95
Margins and nodes for gastric CA
5-6 cm
| 16 nodes
96
If injury to spleen occurs during subtotal gastrectomy requiring splenectomy, what should you do?
Perform TOTAL as splenectomy compromises vascular supply of proximal gastric remnant
97
Total gastrectomy - OR
Staging lap
Upper midline incision
Mobilize left lobe of liver by dividing left triangular ligament**
Separate omentum from transverse colon and proceed toward proximal greater curvature using Ligasure, dividing short gastrics
Divide R gastroepiploic a and v
Mobilize lesser curvature (being mindful of replaced or accessory left hepatic a)
R gastric artery, arising from CHA, is divided
Divide duodenum distal to pyloric ring using TA stapler and oversew staple line with 3-0 silk lemberts
Left gastric a divided at origin at celiac trunk
Divide peritoneum. anterior to GEJ and mobilize intrathoracic esophagus to provide a proximal margin of 5 cm - divide esophagus
Stapled end to end roux en y esophagojejunostomy
Fashion a roux en y jejunal limb 40-60 cm long to avoid biliary reflux
Bring limb retrocolic
Close defect
